Caring for the Older Adult at Risk for Falling

The Centers for Medicare and Medicaid Services lists “Falls” as a never event; non-reimbursable when occurring in hospital settings. Falls represent the leading cause of fatal injury in older adults (CDC, 2017). Older adults are among the patients at greatest risks for complications related to falls. Falls in community settings are the most common case of nonfatal trauma related hospital admissions. Managing falls cost over 50 billion dollars annually, with the majority of the burden placed on Medicare and Medicaid (CDC, 2017). Older adults are often very aware of the repercussions of falls resulting in anxiety and a loss of confidence. Conversely many older adults feel a loss of independence related to the strict fall prevention guidelines implemented in health care settings. Risk and benefit discussions are vital in planning and implementing fall prevention practices that allow for older adults to feel secure and demonstrate autonomy in their own care. This teaching strategy will guide faculty to teach nursing students how to use nursing judgment when weighing the risks and benefits of preventing falls in older adults. It can be utilized in a variety of teaching/learning situations: didactic lectures; clinical settings such as post- clinical conference/debriefings; simulation scenario debriefings; or small seminar discussions. In addition, the teaching strategy can be used with practicing nurses as a professional development activity, as well as with orienting new nurses.

This teaching strategy focuses on assessing expectations, coordinating and managing care, and making situational decisions with older adults. The strategy enhances the student’s human flourishing and nursing judgment.

Provide the learners with the ACE.S framework and discuss communication techniques when assessing function and expectations in older adults.

Using the ACE.S framework, ask the learners to discuss a situation where they were unsure how to balance the expectations of the patient with the institution’s protocol and safety guidelines related to falls precautions when caring for the older adult.

Ask the students to review the tools frequently used to assess fall risk in older adults:

1. Present the case study to the group to begin a discussion. This activity can take place in lecture, seminar, or in pre or post conference for clinical.

Case Study:

Mrs. Hernandez is a 78-year-old female residing in an assisted living facility. She frequently complains of feeling dizzy when she wakes up in the morning and when she gets out of her chair. She describes feeling light headed and has visual difficulties. Her past medical history is significant for diabetes type 2, congestive heart failure, hypothyroidism, atrial fibrillation, angina and major depression. Her current medications include sertraline 50mg daily, nortriptyline 25mg, levothyroxine 01mg daily, warfarin 5mg daily, furosemide 20mg twice a day, glipizide 5mg daily, prn acetaminophen, prn meclizine (25mg q 8 hours), She has been having difficulty sleeping and was recently prescribed diphenhydramine 50mg prn at night. She has been taking the diphenhydramine for the past few nights and feels like she is sleeping better. She has admitted that she sometimes does not take her “water pill” even though “they think I do” because she has to get up too frequently to go to the bathroom. She is looking forward to going to a family outing in two weeks but worries about the dizziness, “I don’t want to be a burden and ruin everybody’s fun.” The nurses in the assisted living facility are very concerned with Mrs. Hernandez’s fall risk and have told her that she cannot get up alone. She does not want to ask for help because she knows that “everybody is busy.” Subsequently she rarely gets up to walk, and finds that she spends most of her day sitting in front of the television. While Mrs. Hernandez has not had any falls over the past two weeks, she also has subjectively stated that she feels “bored and more depressed.”

Discussion Questions: Use the following to facilitate a discussion with your students related to the case study presented:

What are your concerns? What is the cause of the concern?

What else do you need to know about this situation?

What are you going to do about it?

What do you think the patient is experiencing?

Consider the possible outcomes of implementing falls precautions or not. What are the risks and benefits to the patient? To the nurse?

2. Have the students investigate the Older Adult Falls Prevention Program from the CDC Stopping Elderly Accidents, Deaths and Injuries (STEADI)https://www.cdc.gov/steadi/materials.html. Ask them to design a falls prevention program for older adults in various settings using these resources as well as the how to try this tools.

3. As an intraprofessional activity ask students to collaborate with physical and occupational therapy to guide a strengthening program appropriate to the setting. The Get up and Go test; part of Hendrich II Falls Assessment Tool can be used as a group activity in collaboration with physical and occupational therapy. If there is a Tai Chi expert, they can adapt the program to include this approach to improve balance.

ConsultGeri.org, the website of the Hartford Institute for Geriatric Nursing at New York University’s College of Nursing, contains many evidence-based assessment tools. Located on the ConsultGeri website is a variety of assessment tools on topics relevant to the care of older adults. The How to Try This series is comprised of articles and videos demonstrating the use of the Try This:® series. How to Try This articles and videos are listed under their respective Try This article. Those listed below can be used to assess, evaluate, and discuss the needs of older adults with students. Visit ConsultGeri.org to access the Try This® and How to Try This resources.